Urology Studies

HISTORY AND PHYSICAL EXAMINATION

This 34-year-old man is here for a general physical, which he has not had for some time.  He has been working 75 hours a week and not eating as well, also drinking about 2 beers 3 times a week.  Does have some increased fatigue which is described as mild.  Has a 6-month history of intermittent urinary frequency, with passing small quantities for 1 to 7 days.  This has recurred after several weeks on several occasions and has had rare episodes of dysuria.  Had 1 episode of clear discharge for about 3 days.  Has occasional depression.  Gets blisters on his hands which come and go and seem to be related to stress.  Has periodic eruptions on the scalp.

PAST MEDICAL HISTORY

T&A.

ALLERGIES

None known.

REVIEW OF SYSTEMS

Has geographic tongue.  Has rare episodes of bleeding on toilet tissue.

FAMILY HISTORY

Mother had seizures.  Father has history of melanoma.  Brother has overactive thyroid.  There is cancer, heart disease, and diabetes in the grandparents.

HABITS

Alcohol:  Moderate.  Diet:  Skips breakfast and has been eating less healthy food of late.

PHYSICAL EXAMINATION

GENERAL:  He is 5 feet 6 inches, 130 pounds.

VITAL SIGNS:  Blood pressure 120/80, pulse 72.

HEENT:  Normal.

NECK:  Normal.

HEART:  Normal.

LUNGS:  Normal.

ABDOMEN:  Normal.

PULSES:  Normal.

EXTREMITIES:  Normal.

GROSS NEUROLOGIC EXAM:  Normal.

SKIN:  Normal.

RECTAL:  Rectal exam reveals a 0.67-cm nodule on the left side of the prostate, which is nontender.

ASSESSMENT

1. Mild fatigue.

2. Intermittent urinary frequency with history of discharge and dysuria.

3. Periodic depression.

4. Prostate nodule.

5. Occasional lesions on scalp, possibly psoriatic.

PLAN

Will see urologist concerning his prostate nodule.  Otherwise, screening tests from laboratory, dietary recommendations, and supplements as noted.  Followup in 6 weeks.

FOOTNOTE

Line 12 (Page 1).  Alternative:  1-7.

Line 38 (Page 1).  The title Exam was expanded to Physical Examination.

Line 39 (Page 1).  He is was added to avoid beginning the sentence with a numeral.

Line 1 (Page 2).  Two-thirds centimeter was converted to its metric equipment, 0.67 cm.  (The actual value is 0.6666..., and it was rounded off.)

Line 10 (Page 2).  The dictator’s error was corrected; the number 3 was changed to 5.

Line 15 (Page 2).  Alternative:  Follow up (verb).